Thrombophlebitis, also known as Peripheral Vascular Disease (PVD) is the inflammation of veins resulting in the formation of blood clots (thrombosis) that interfere the normal blood flow in the extremities. Typically, PVD occurs in the legs and feet. PVD in deep veins can be life-threatening because clots may travel to the bloodstream and cause a pulmonary embolism. The nursing care plan for the client with deep vein thrombosis includes prevention teaching (exercise, diet, proper application of anti-embolism stockings), providing information regarding disease condition, assessing and monitoring anticoagulant therapy, providing comfort measures, positioning the body and encouraging exercise.
Nursing Assessment for PVD
1. Assess for the signs and symptoms of deep vein thrombosis (DVT). Swelling, pain or tenderness, increased warmth, and changes in skin color (redness).
2. Measure circumference of the affected leg with a tape measure: Unilateral leg and thigh swelling can be assessed by measuring the circumference of the affected leg right above the knee. Deep vein thrombosis is suspected if there is a difference of greater than 1/2 inch between the extremities.
3. Monitor the following coagulation profile:
- International normalized ratio (INR). An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking warfarin for disorders such as blood clots in the leg or lung.
- Prothrombin time (PT). The reference range for prothrombin time is 9.5-13.5 seconds.
- Partial thromboplastin time (PTT). Normal results are typically 25 to 35 seconds.
The PT/INR is used for clients receiving warfarin. Baseline values are obtained before the first dose of anticoagulant is administered. Repeated tests are done at prescribed intervals to adjust drug dosages to achieved desired changes in coagulation.
4. Maintain adequate hydration. Hydration prevents increased viscosity of blood which contributes to clotting.
5. Encourage bedrest and keep the affected leg elevated (depending on size and location of the clot). The patient should be on bed rest until symptoms are relieved. The affected leg should be elevated to a position above the heart to decrease swelling.
6. Apply below-knee compression stockings as prescribed. Ensure that the stockings are the correct size and are applied correctly. Compression stockings encourage circulation by providing pressure on the affected leg to help return the venous blood to the heart. Inaccurately applied stockings can create/promote clot formation.
7. Investigate reports of sudden or sharp chest pain. Also monitor dyspnea, tachycardia, and apprehension, or development of a new pain. These symptoms suggest pulmonary embolism - a complication of DVT or peripheral arterial occlusion. Both conditions require immediate medical treatment.
8. Monitor vital signs, noting increased temperature. Elevations in heart rate occurs in response to fever and inflammatory process. Fever can also increase the patient’s discomfort.
9. Teach the patient to maintain bed rest during an acute phase. This will decrease discomfort associated with muscle contraction and movement.
10. If on bedrest, encourage the patient to change position frequently. Reduces muscle fatigue, helps minimize muscle spasm and maximizes circulation to tissues.
Tips for completing OASIS-D M1028 Peripheral Vascular Disease (PVD)
- There must be specific documentation in the medical record by a physician (or nurse practitioner, physician assistant, clinical nurse specialist, or other authorized staff if allowable under state licensure laws) of the disease or condition being an active diagnosis.
- The physician (nurse practitioner, physician assistant, clinical nurse specialist, authorized licensed staff if allowable under state licensure laws) may specifically indicate that a diagnosis is active. Specific documentation areas in the medical record may include, but are not limited to, progress notes, admission history and physical, transfer notes, and the hospital discharge summary.
- The physician (nurse practitioner, physician assistant, clinical nurse specialist or other authorized licensed staff if allowable under state licensure laws) for example, documents at the time of assessment that the patient has inadequately controlled diabetes and requires adjustment of the medication regimen. This would be sufficient documentation of an active diagnosis and would require no additional confirmation because the physician documented the diagnosis and also confirmed that the mediation regimen needed to be modified.
- For the purposes of the OASIS Data Set, Home Health Agencies should consider only the documented active diagnoses. A diagnosis should not be inferred by association with other conditions (e.g., “weight loss” should not be inferred to mean “malnutrition”).